The Aetiology and Impact of Complex Trauma on Interpersonal Relationships: An Argument for Trauma-Informed Care in Forensic Mental Health Services
Research into the symptoms presented by those who have experienced complex trauma has increasingly indicated that complex post-traumatic stress disorder should be considered distinct from post-traumatic stress disorder and that care needs should be adjusted accordingly. The present essay will assert that trauma-focused therapies and a trauma-informed care approach can be effectively combined to reduce the long term impact of complex trauma on inpatients of forensic mental health services.
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Trauma can result in psychological symptoms recognised as post-traumatic stress disorder (PTSD) or complex PTSD (CPTSD) (Davey, Lake & Whittington, 2015). Experiencing or witnessing near or actual death, sexual assault or serious injury can create distress from reliving the traumatic incident via intrusive memories or flashbacks, nightmares and frequently a desire to avoid reminders of the event. The individual can then experience a persistent sense of imminent danger and hyper-vigilance affecting sleep, concentration and mood regulation. Dissociation can occur as depersonalisation, a sense of detachment from one’s own thoughts and experiences and a perceived derealisation of self and surroundings (American Psychiatric Association, 2013; Davey et al., 2015).
Although not yet a formal psychiatric diagnosis, CPTSD, identified by Herman (1992) (Davey, Lake & Whittington, 2015) and present in the 11th revision of the International Classification of Diseases manual (ICD-11) differentiates between symptoms of PTSD and others specifically resulting from chronic victimisation and control by others. CPTSD acknowledges persistent and pervasive issues with ’disturbances of self-organisation’ (DSO) spanning differing contexts and without reminders of the trauma (Hyland, Murphy, Shevlin, Vallieres, McElroy, Elklit, Christofferson & Cloitre, 2017). CPTSD comprises exposure to frequent and repeated occurrences of interpersonal trauma in multiple forms during childhood, which negatively impacts development of emotional regulation, exacerbates dysfunctional self-perception and impairs interpersonal functioning into adulthood (Hyland et al., 2017).
Complex trauma can occur from abuse or neglect during neurodevelopment and influence brain structure development and its functions, for example, the pattern of neuronal activity that repeated traumatic experiences activate in the frontal lobe (Davey, Lake & Whittington, 2015; Glaser, 2000). If regular sensitive interpersonal interactions do not take place between the caregiver and infant, ontogenesis, the development of self-regulation ability based on genes and environment, is negatively affected, often later manifesting in aggression or hypervigilance (Glaser, 2000). Information gathered through the senses at each abusive encounter creates a ‘processing template’ to filter new information which may threaten survival. This results in exaggerated sensitivity to daily events, over time moving the child’s anxious reaction to trauma from a temporary state to a persistent trait. Long term emotional, cognitive and behavioural problems then emerge from their original adaptive response to trauma (Perry, Pollard, Blakley, Baker, & Vigilante, 1995).
Damage from early life trauma can lead to crime in adulthood (Ardino, 2012; Morris, 2019; Spitzer, Chevalier, Gillner, Freyberger, & Barnow, 2006). Mental health issues can be triggered by a childhood saturated with stress, or Adverse Childhood Experiences (ACEs) (Morris, 2019). In the U.S.A., a history of abuse or neglect in childhood has been found to raise the likelihood of criminal behaviour as an adult by 28% (Widom & Maxfield, 2001). Reactions to trauma, e.g.: aggression can lead to maladaptive coping mechanisms including substance misuse and interpersonal conflict. The cvcle of violence theory (Widom & Maxfield, 2001) postulates that growing up in a dysfunctional lifestyle moulds the individual from victim into perpetrator (Ardino, 2012). Serious mental health related offences, challenging behaviour, an individual becoming a risk to themselves or others or their care needs exceeding the capacity of a general inpatient unit can lead to admission to a mental health secure unit (Centre for Mental Health, 2011).
National Institute for Clinical Excellence (NICE, 2018) guidelines have highlighted Trauma-focused Cognitive Behavioural Therapy (TF-CBT) and Eye Movement Desensitisation and Reprogramming (EMDR) as approaches that should be offered to clients diagnosed specifically with PTSD, both postulated to be effective for improving the individual’s view of self and others as cognitive restructuring can be brought about by retelling the trauma, which alters the client’s view of themselves and their experiences (Davey, Lake & Whittington, 2015).
TF-CBT uses ‘imaginal exposure’ through detailed ‘reliving’ of the trauma or ‘in vivo exposure’ when the traumatic location is physically revisited. Prolonged exposure therapy has been found highly effective for rape victims, hence the complications from sexual abuse in childhood can arguably be reduced in adulthood. The effectiveness of exposure therapy is attributed to the fine detail that is recalled, resulting in the client being able to draw more positive and realistic conclusions from the experience, such as no longer placing blame on themselves for how the trauma occurred (Davey, Lake & Whittington, 2015).
EMDR therapy, from the Adaptive Information Processing Model (Shapiro, 2001), is designed to promote physiological healing in the brain after trauma has occurred and either the natural healing process has been blocked or repeated trauma has taken place. Shapiro proposed that the brain is designed to tackle maladaptive material by assigning it adaptive purpose within the context of a healthy mind. Interruption of this process results in the individual remaining psychologically trapped in the traumatic event, giving dual attention to the past and the present, unable to absorb more adaptive material. EMDR targets the thoughts, feelings and sensations of the traumatic memory by engaging both brain hemispheres by means bilateral visual, auditory or physical sensations. Three treatment phases comprising stabilising of disturbing symptoms such as dissociation, reprocessing of traumatic memories and then working on the transition from therapy to reality are achieved using a combination of CBT, EMDR and other evidence-based trauma therapies where appropriate (Davey, Lake & Whittington, 2015). Throughout the therapeutic process, NICE (2018) guidelines for CPTSD recommend additionally the development of trust through additional time spent on therapy sessions, along with consideration of personal circumstances, degree of symptom manifestation and any other barriers, such as substance misuse, that might impact treatment engagement.
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As CPTSD is a newly emerging diagnosis, the condition has no direct clinical evidence to date to support a separate treatment approach to that for PTSD. However, a recent systematic review and meta-analysis (Karatzias, et al., 2019) examining treatments for PTSD and CPSTD as individual symptom clusters revealed that cognitive-behavioural and EMDR therapies generated stronger outcomes than treatment as usual or no intervention. Participants whose onset of trauma took place in childhood were found to benefit the least from these interventions, however this was found to be the case across all interventions reviewed (International Society for Traumatic Stress Studies, 2019). It is arguably crucial to recognise and diagnose CPTSD as distinct from PTSD in order to offer specific effective psychological interventions that enable recovery from complex trauma.
The culture of forensic settings can be used as an intervention by means of taking a trauma-informed care approach (Miller & Najavits, 2012). Social support (SUP), interaction between two or more people aimed at solving a problematic state, has been proposed as a core intervention to break the cycle of violence (Krammer, Eisenbarth, Hugli, Liebrenz, & Kuwert, 2017). A meta-analysis of 103 studies highlighted SUP as a key factor for post-traumatic growth. As those who have experienced trauma can struggle with interpersonal functioning, a secure unit can arguably evoke traumatic memories and trigger emotional reactions to systems and staff encountered (Morris, 2019). The atmosphere can mirror previous traumatic experiences, e.g.: control of behaviour and activities, such as meal and sleep times. However, by practicing trauma-informed care, time as an inpatient can be reframed as an opportunity for the client to recognise where their thoughts, feelings and behaviours have originated from and for the care that they did not receive while growing up to now be offered by staff (Morris, 2019).
Training and supervision can be used to educate and guide staff to cultivate empathy and compassion for inpatients (Miller & Najavits, 2012). Impairment in interpersonal functioning can manifest as aggression which staff can find challenging (Beckett et al., 2017). Early life experiences of staff ought to be considered alongside those of the client in terms of countertransference of emotions (Morris, 2019; Miller & Najavits, 2012). A clash of perspectives can create a battle for power if staff perceive they are being manipulated by their client (Morris, 2019). Support to recognise and tackle this risk can be introduced by using, for example, the Seesaw Boundary Model (Hamilton, 2010) which seeks to find balance between care and control by placing the staff member as a nurturing and empowering negotiator rather than pacifying carer or punishing controller.
Evidence suggests that early intervention for complex trauma could reduce rates of admission to forensic units in adulthood by halting neurodevelopmental damage caused by ACEs and preventing or limiting internal and interpersonal maladaptive changes that lead to offending. Trauma-informed care is arguably an effective method to reduce effects of trauma by being sensitive to the history that has shaped a client’s present state. By training staff to deliver effective trauma-focused therapies with ongoing support once they conclude, the client can heal and develop a deeper understanding and greater positive regard for themselves and others, while breaking the cycle of violence.
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